Discussion Board

A very important aspect of healthcare administration is avoiding never events as these are termed. Give an example of a never event, and explain how you would respond to such an event taking place in your own healthcare facility. Also, as hospital CEO, how would you work to prevent never events in your organization moving forward?

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A 65 year old woman presented at Massachusetts General for a trigger finger release operation. Due to a series of errors, staff changes, and delays, the physician performed a carpel tunnel release. Fifteen minutes after the operation, as he was dictating the details of the procedures for inclusion in the patients EHR, he realized his error. In this instance, the physician immediately took responsibility for his error and performed the correct operation at no charge to the patient.  As CEO, I would look at the series of errors that led up to the event and take corrective action going foward. The ‘time out’ was not properly performed, and there was a staff change up in the OR just before the operation commenced. It seemed like a rather chaotic time for all involved. I would instigate a checklist forr all operations and procedures, whether unusual in circumstance or not.